Letters to the Editor that Dr Woodford Williams describes in her excellent report. It is to be hoped that the Secretary of State will be able to read and appreciate the lesson so clearly defined in this report, which should give him much ground for constructive thought. Yours faithfully AMULREE
6June 1976
Cervical Lymph Node Metastases
537
indicated in patients with antral carcinoma and a node in the neck. No reference is made to any 'level' in the neck. A single node high in the neck and on the same side should certainly be treated when operable and the primary controlled. The situations quoted do offer a poorer prognosis, but when each patient is considered there must be room for attempts at surgical salvage. Finally, nowhere in this paper is there any reference to combined treatment with irradiation for neck metastases. In the paper by Dr Pointon and Mr Jelly (p 414), the conclusions reached are most valuable since they are based on a wide surgical experience of neck metastases from mouth cancer. It is surprising, however, that they do not mention the Commando type of operation for combined removal of lymphatics and primary in the more advanced lesions when reporting up to 1969. I am pleased to note the evidence for condemnation of suprahyoid neck dissection and their emphasis that bilateral neck dissection did increase the survival time for an appreciable number of their patients. Yours sincerely
From Mr H J Shaw Chairman, Head anid Neck Unit, The Royal Marsden Hospital, Lonidon SW3 Sir, I was greatly interested in the papers published under the Section of Laryngology in the June issue (p 409). As no discussion was published perhaps you will permit these observations. The three principal papers all relate to the problem of metastatic cancer in the lymph nodes of the head and neck. Mr Peter McKelvie deserves praise for his painstaking work in the study of neck dissection specimens and the penetration of the lymph node system by tumour cells, H J SHAW although his account is at times difficult to 9June 1976 follow. As a surgeon I am particularly pleased to [Dr Pointon comments: In the series reported, no see his description of functional neck dissection operation that could be called 'Commando' type for cancer as surgical 'brinkmanship', and also was carried out]. that he found no local signs that removal of involved nodes was detrimental immunologically. From Dr A Levene The paper by Mr Stell and Dr Green (p 41 1) on Consultant Pathologist, management of metastases to the lymph glands Royal Marsden Hospital, Londoni SW3 of the neck is also very welcome', but the dog- Dear Sir, I found the paper by McKelvie (June matic attitudes expressed would seem based on Proceedings, p 409) confusing in both intent and slender evidence. The statement that there is no presentation. He says 'The dissection follows the evidence that prophylactic neck dissection in- route of a functional neck dissection, in which a creases survival time for patients with cancer of sleeve of tissues suspending the lymph node field the head and neck is a generalization based on is dissected out' without any indication of what the study of a very small number of paired the term 'functional neck dissection' means or patients and relating only to cancer of the larynx how the lymph node field is to be suspended. He and pharynx. In the latter group there is only one proceeds: '. . . functional neck dissection is a form T3 tumour quoted. Surely it is in well lateralized of surgical brinkmanship, in that microscopically T3 tumours of the tongue, floor of mouth and involved nodes have been seen hard against and pharynx that prophylactic or elective neck involving the adventitia of the internal jugular dissection has a real value when combined with vein'. What does this mean? A little later when he refers to the 'relentlessly rolling steep wave of resection of the primary lesion. Two other statements in this paper require squamous cell carcinoma' he mentions that he qualification in relation to the whole field of head searched for 'signs that the tumour had abated, and neck cancer. First; that surgery is contra- retreated over its tracks, or hesitated, but no such indicated in cases with bilateral neck metastases signs were found'. Presumably he does not mean since it does not increase survival time. I presume that he has never seen spontaneous necrosis of this refers only to squamous cancer of the pharynx metastatic squamous cell carcinoma or the foror larynx. In metastatic differentiated' thyroid mation of keratin granuloma where squamous gland cancer or in some malignant tumours of cell carcinoma previously existed. the nasopharynx the point is certainly very Of the paper by Pointon & Jelly (p 414) there is debatable if the primary lesion can be eradicated. nothing to say other than that it is a factual Secondly, that surgery is probably contra- account of work they have carried out, with some
6June 1976
Cervical Lymph Node Metastases
537
indicated in patients with antral carcinoma and a node in the neck. No reference is made to any 'level' in the neck. A single node high in the neck and on the same side should certainly be treated when operable and the primary controlled. The situations quoted do offer a poorer prognosis, but when each patient is considered there must be room for attempts at surgical salvage. Finally, nowhere in this paper is there any reference to combined treatment with irradiation for neck metastases. In the paper by Dr Pointon and Mr Jelly (p 414), the conclusions reached are most valuable since they are based on a wide surgical experience of neck metastases from mouth cancer. It is surprising, however, that they do not mention the Commando type of operation for combined removal of lymphatics and primary in the more advanced lesions when reporting up to 1969. I am pleased to note the evidence for condemnation of suprahyoid neck dissection and their emphasis that bilateral neck dissection did increase the survival time for an appreciable number of their patients. Yours sincerely
From Mr H J Shaw Chairman, Head anid Neck Unit, The Royal Marsden Hospital, Lonidon SW3 Sir, I was greatly interested in the papers published under the Section of Laryngology in the June issue (p 409). As no discussion was published perhaps you will permit these observations. The three principal papers all relate to the problem of metastatic cancer in the lymph nodes of the head and neck. Mr Peter McKelvie deserves praise for his painstaking work in the study of neck dissection specimens and the penetration of the lymph node system by tumour cells, H J SHAW although his account is at times difficult to 9June 1976 follow. As a surgeon I am particularly pleased to [Dr Pointon comments: In the series reported, no see his description of functional neck dissection operation that could be called 'Commando' type for cancer as surgical 'brinkmanship', and also was carried out]. that he found no local signs that removal of involved nodes was detrimental immunologically. From Dr A Levene The paper by Mr Stell and Dr Green (p 41 1) on Consultant Pathologist, management of metastases to the lymph glands Royal Marsden Hospital, Londoni SW3 of the neck is also very welcome', but the dog- Dear Sir, I found the paper by McKelvie (June matic attitudes expressed would seem based on Proceedings, p 409) confusing in both intent and slender evidence. The statement that there is no presentation. He says 'The dissection follows the evidence that prophylactic neck dissection in- route of a functional neck dissection, in which a creases survival time for patients with cancer of sleeve of tissues suspending the lymph node field the head and neck is a generalization based on is dissected out' without any indication of what the study of a very small number of paired the term 'functional neck dissection' means or patients and relating only to cancer of the larynx how the lymph node field is to be suspended. He and pharynx. In the latter group there is only one proceeds: '. . . functional neck dissection is a form T3 tumour quoted. Surely it is in well lateralized of surgical brinkmanship, in that microscopically T3 tumours of the tongue, floor of mouth and involved nodes have been seen hard against and pharynx that prophylactic or elective neck involving the adventitia of the internal jugular dissection has a real value when combined with vein'. What does this mean? A little later when he refers to the 'relentlessly rolling steep wave of resection of the primary lesion. Two other statements in this paper require squamous cell carcinoma' he mentions that he qualification in relation to the whole field of head searched for 'signs that the tumour had abated, and neck cancer. First; that surgery is contra- retreated over its tracks, or hesitated, but no such indicated in cases with bilateral neck metastases signs were found'. Presumably he does not mean since it does not increase survival time. I presume that he has never seen spontaneous necrosis of this refers only to squamous cancer of the pharynx metastatic squamous cell carcinoma or the foror larynx. In metastatic differentiated' thyroid mation of keratin granuloma where squamous gland cancer or in some malignant tumours of cell carcinoma previously existed. the nasopharynx the point is certainly very Of the paper by Pointon & Jelly (p 414) there is debatable if the primary lesion can be eradicated. nothing to say other than that it is a factual Secondly, that surgery is probably contra- account of work they have carried out, with some
